Coder lll - FT Days -Coding - 10063

Coder Lll - FT Days - Coding

DHR Health - US:TX:McAllen - Days

Summary:

POSITION SUMMARY:

The Inpatient coder reviews and analyzes documentation in the medical record for inpatient visits to ensure accuracy of diagnosis and procedure codes. Coder finalizes the coding and abstracting of the medical record according to ICD-10-CM/PCS, CPT, and HCPCS coding conventions and guidelines supported by the clinical documentation in the medical record. Coder analyzes diagnosis and procedure codes concurrently assigned by Clinical Documentation Specialists. The Inpatient Coder assumes primary responsibility for DRG validation/accuracy, primary role in assisting CDS and medical staff members with improving quality of clinical documentation. Sequence the diagnoses and procedures using official coding guidelines. Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges. Resolve Inpatient billing edits. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).

POSITION EDUCATION/QUALIFICATIONS:

RHIA, RHIT, CCS or CIC required. Three to five years hospital experience required.

JOB KNOWLEDGE/EXPERIENCE:

Experience and/or advanced training in medical coding (MS/APR DRG's, ICD-10-CM, CPT, HCPCS, etc.)

Must have extensive knowledge of medical terminology, anatomy and physiology, knowledge of pharmacology and all major diseases

Requires reasoning ability and good independent judgment.

Critical thinking skills are a must. Must have strong interpersonal skills and the ability to multi-task

3M CRS software experienced preferred

Requires good communication and organizational skills

Must have an understanding of laws and ethics related to health insurance, medical billing and the Health Insurance Portability and Accountability Act (HIPAA)

Requires working with minimal to moderate interruptions.

Must complete CE hours annually, according to certification requirements Professional coding and billing experience a plus

Responsibilities:

POSITION RESPONSIBILITES:

Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices

Accurately codes all inpatient diagnoses and procedures according to ICD-10-CM/PCS, CPT and HCPCS coding conventions and guidelines.

Follows the AHIMA Standards of Ethical Coding to adhere to Coding Compliance guidelines.

References ICD-10-CM/PCS, CPT, and HCPCS Level II code books as needed.

Accurately attach HCPCS level I and level II modifiers when appropriate

Utilizes 3M Coding references daily for final coding

Utilizes computerized 3M Coding Software.

Meets quality standards of having 95% of charts coded accurately.

Maintains a good working relationship within the department, other departments and medical staff

Codes all available records in a timely manner.

Queries physicians for clarification when ambiguous or incomplete information is present.

Communicates with Coding Manager to solve problems and to clarify coding issues.

Attends workshops, seminars or conferences that pertain to position and that fulfill CE hour requirements

Reviews Coding Clinic updates and continuing education periodicals in a timely manner

Maintain ongoing education to stay abreast of updates in coding conventions and practices

Assists the business office with clearing reimbursement and denial issues

Clears Aeos in a timely manner

Notify HIM staff of incomplete or un-scanned records through the tickler system

Adheres to the Health Information Management Policies and Procedures for coding.

Adheres to the Coding Compliance Plan.

In case of any inaccuracies or discrepancies in the medical record, then it is his or her responsibility to report the matter to the appropriate department so that the necessary corrections can be made

Maintains confidentiality and safeguards all patient related information

Ability to train and mentor junior staff members

Performs Peer review and internal audits

Performs other duties as assigned